P1
Minimally Invasive Approach in Consecutive Patients With Aortic Aneurysms
Jakub P. Staromłyński, Radosław Smoczynski, Anna Witkowska, Pawel Stachurski, Wojciech Sarnowski, Piotr Suwalski. Central Clinical Hospital of the Ministry of Interior, Warsaw, Poland.
Objective: Minimally invasive cardiac surgery is becoming more and more popular. However, there are still few data on a minimally invasive approach for patients with aortic aneurysm.
Methods: Between November 2011 and November 2016, 103 patients with aortic aneurysms were included in our study. Surgical access was via a minimally invasive upper partial V sternotomy through the third or fourth intercostal space. Cardiopulmonary bypass was provided via direct aortic cannulation and a 2-stage cannula to the right atrium. Based on our previous experience, we set that 70 mm of aortic diameter as an exclusion criterion for the minimally invasive approach. Results: We performed 103 minimally invasive procedures in 67 patients (47.8%); supracoronary graft in 29 patients (20.7%); supracoronary graft and AVR in 26 patients (18.5%); the Bentall proce-dure (mechanical graft) in 10 patients (7.1%); and the David proceproce-dure in 8 patients (5.3%). The mean (SD) age was 62.9 ± 12.0 years; and the mean body mass index (kg/m2) was 29.0 ± 4.4. Preoperative co-morbidities included insulin-dependent diabetes mellitus in 12.6% and previous percutaneous coronary intervention in 4.8. The mean ejection fraction was 58.2 ± 7.8%. The mean EuroSCORE II was 2.6 ± 3.0%. We did not observe conversion to full median sternotomy in any of the groups. Reopening for bleeding was necessary in 5 patients (4.8%). We did not observe any neurological incidents, deep wound infections, or vascular complications. In 5 patients, superficial wound infections required local antibiotic therapy. The average stay in the intensive care unit was 2.2 ± 2.1 days. In first 12 hours, 68% of pa-tients were extubated. During the first 24 hours, we observed mean drainage of 357.4 ± 206.4 ml. The blood transfusion rate was 0.8 ± 1.2; the platelet transfusion rate was 0.3 ± 1.2; the 30-day mor-tality rate was 0.97%.
Conclusions: Minimally invasive procedures via a minimally invasive upper partial V sternotomy are safe and feasible operative methods. They provide better hemostasis due to decreased tissue traumatization. The small incision and the partial upper sternotomy enable faster recov-ery. In this group of patients, the greatest benefits were early extubation (chest stability) and few in-hospital deaths.
P2
Hybrid Surgery for Complex Aortic Dissecting Aneurysm An T. Nguyen, Tien Quyet Tran. Cho Ray Hospital, Ho Chi Minh City, Vietnam. Objective: Our goal was to estimate the safety and results of thoracic endovascular aortic repair (TEVAR) combined with open surgery for extensive aortic dissecting aneurysms.
Methods: We performed an observational prospective study from 2013 to 2016. Of the 18 patients, 13 were men and 5 were women. The aver-age number of stents was 1.83. The 30-day mortality rate was 5.56%. The average age was 60.06 years. Patients with extensive aortic dissect-ing aneurysms were treated with open replacement of the ascenddissect-ing arch, then with TEVAR, which landed on the prosthesis to cover the de-scending disease. The oversize rate was 20% to 30%, and the length of the landing zone was 3 to 5 cm.
Results: The patients were followed up with a contrast computed tomography scan at 1 and 3 months and then every 12 months
postoperatively. No endoleak type 1 was observed. The survival rate was 16/17 (94%).
Conclusions: TEVAR and open surgery are useful and safe for treat-ment of complex aortic dissecting aneurysms.
P3
Minimally Invasive Aortic Repair for Thoracic Aortic Aneurysm Daisuke Yasumizu, Takashi Murakami, Hiromichi Fujii, Masanori Sakaguchi, Yosuke Takahashi, Shisuke Nishimura, Yoshito Sakon, Toshihiko Shibata. Osaka City University, Osaka, Japan.
Objective: Minimally invasive procedures have been widely adopted in contemporary cardiac surgery because of the several advantages they provide. However, the surgical management of thoracic aortic aneurysms (TAA) remains a complex and challenging process. Our goal was to describe our preliminary experiences with mini-mally invasive aortic repair for TAA via a partial upper sternotomy in 6 patients.
Methods: This retrospective study included 6 patients who underwent minimally invasive aortic repair for TAA between May 2016 and December 2016. Indications for minimally invasive aortic repair were (1) predicted distal anastomosis close to the sternum; (2) supra-aortic vessels close to the sternum when total arch replacement (TAR) was in-dicated; and (3) aneurysms limited to the ascending aorta. For TAR, antegrade cerebral perfusion was used, and for hemiarch replacement, retrograde cerebral perfusion was used. Body temperature during circu-latory arrest was 25 °C in all cases. The mean age was 71 years, and 4 patients (66%) were men.
Results: The surgical procedure was successfully completed in all pa-tients without conversion to full sternotomy. Three papa-tients underwent TAR with the frozen elephant trunk technique, and others underwent as-cending aortic replacement. Concomitant operations included aortic valve repair in 2 patients and aortic valve replacement in 1. There were no perioperative or 30-day deaths. The mean cardiopulmonary bypass time was 217 minutes, and the circulatory arrest time was 43 minutes. Even with moderate hypothermia, circulatory arrest with retrograde ce-rebral perfusion was well tolerated for 27 to 41 minutes. No postopera-tive permanent neurological complication occurred. Three patients (50%) experienced pericardiocentesis.
Conclusions: Our preliminary experience suggests that minimally invasive aortic repair for TAA is feasible and could be safely per-formed despite a limited operative field, without compromising sur-gical outcomes.
P4
Aortic Arch Repair With Single-Stage Hybrid Antegrade Thoracic Endovascular Aortic Repair Versus 2-Stage Hybrid Repair Mahmoud Alhussaini1, Seyed Hossein Aalaei Andabili1, Salvatore Scali2, Robert J. Feezor2, Tomas Martin3, Philip Hess4, Charles Klodell1, Teng C. Lee1, George Arnaoutakis1, Thomas Beaver1.1
Division of Thoracic and Cardiovascular Surgery and2Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL USA;3Cardiovascular Surgical Services at Florida Hospital, Orlando, FL USA; and4Division of Thoracic and Cardiovascular Surgery, Depart-ment of Surgery, Indiana University, Indianapolis, IN USA.
Objective: We compared outcomes of single-stage hybrid arch replace-ment using antegrade thoracic endovascular aortic repair (TEVAR) (fro-zen elephant trunk technique) versus 2-stage hybrid repair with the arch debranching/elephant trunk procedure in the first and TEVAR in the second stage.
Methods: We performed a single-center retrospective review (2003–2016) of 118 patients undergoing hybrid repair of the aortic arch with TEVAR at our university: 48 single-stage repairs versus 70 two-stage repairs. Pa-tient demographics and intraoperative and postoperative outcomes were reviewed.
Results: Forty-eight patients including 31 (64.6%) men and 17 (35.4%) women with a mean ± SD age of 64 ± 11 years underwent a single-stage procedure; 70 patients, including 42 (60%) men and 28 (40%) women with a mean ± SD age of 65.67 ± 13.3 years, underwent a 2-stage procedure (age, P = 0.46). More emergent procedures were per-formed in 23/48 (47.9%) single-stage patients versus 8/70 (11.43%) 2-stage patients (P < 0.001). The mean cardiopulmonary bypass time for a single-stage versus a 2-stage procedure was 267.6 ± 80 hours vs. 212.2 ± 64.9 hours (P < 0.001). Fifty-five (84.62%) first-stage patients completed the second stage. Between the single and the 2-stage groups, there was no difference in stroke [6.25% (3/48) vs. 14.28% (10/70) (P = 0.23)] or spinal cord ischemia [4.16% (2/48) vs. 5.7% (4/70) (P = 1.0)]. There was no difference in the 30-day mortality rate: single stage 9/48 (18.75%) versus the combined 30-day mortality rate of the 2-stage group of 5/70 (16.24%): 7.14% for first stage and 5/55 (9.1%) for the second stage (P = 0.61), respectively. The median follow-up time was 31 months (range, 1–127 months). Overall survival including 30-day mor-tality at months 6 and 12 was single stage 6-months: 75% and 12 months: 75% versus two-stage completion: 6-months: 77% and 12 months: 70% versus first stage only: 6 and 12 months 47% (Fig. P4-1).
Conclusions: Both single-stage and 2-stage hybrid arch replacements are effective approaches for treating complex aortic arch diseases. Early deaths and neurological outcomes in the single-stage group are compara-ble to those in the 2-stage group. Furthermore, in this series, patients who had a single-stage hybrid procedure had a higher survival rate at 2 years.
P5
Challenge to the Aortic Arch Treatment With Fenestrated Stent Graft Hiroyuki Otsuka1, Seiji Onitsuka1, Atsuhisa Tanaka2, Shinichi Nata1, Mau Amako1, Tohru Takaseya1, Satoru Tobinnaga1, Shinichi Hiromatsu1, Hidetoshi Akashi1, Hiroyuki Tanaka1. 1Kurume University School of Medicine, Kurume, Japan; and2Saga University School of Medicine, Saga, Japan.
Objective: Thoracic endovascular aortic repair (TEVAR) has spread widely as treatment of thoracic aortic diseases. However, it is difficult to further expand the indications for simple TEVAR for aortic arch le-sions, because additional management of the brachiocephalic and the left common carotid artery is necessary to secure sufficient length of a proximal neck. The Najuta fenestrated stent graft (Kawasumi, Inc, Tokyo, Japan) has been commercially available in Japan for repairing distal aortic arch aneurysms since June 2013. We evaluated early and mid-term results of TEVAR using the fenestrated stent graft (Najuta SG) as a semi-order device for aortic arch treatment and describe its clinical usefulness and limitations.
Methods: Between January 2007 and May 2016, 29 patients were treated with the Najuta stent graft at our hospital. Early and midterm re-sults were investigated retrospectively. The mean age of the patients was 73.9 years; 27 patients were men. Indications were degenerative aortic aneurysms 22 (76%), chronic aortic dissections 6 (21%), and pseudoaneurysm 1 (3%). Najuta stent grafts were placed in zone 2 (10) and zone 3 (19). These fenestrations preserved antegrade blood flow into the brachiocephalic and the left common carotid arteries. The left subclavian artery was simply covered by the stent graft without any re-construction in the remaining 23 cases (79.5%). Other commercially available tube-type stent grafts were used in 15 cases (52%) due to a short proximal landing zone.
Results: The technical success rate was 100%. The overall 30-day mor-tality rate was 0%. Temporary paraplegia was 3.4%. There were no strokes and no retrograde aortic dissections. The mean follow-up period was 53.9 months. There were no aneurysm-related deaths. A type Ia endoleak was detected in 1 aneurysm. The rate of freedom from second-ary intervention was 93. Device migration was not observed. There was 1 branch (left subclavian artery) occlusion. No other branch occlusion was seen in the follow-up period.
Conclusions: TEVAR using the Najuta stent graft was feasible, demon-strating a high rate of freedom from aneurysm enlargement and a high patency rate of the supra-aortic branches in the treatment of aortic arch diseases.
P6
Combined Aortic Replacement and Stenting of Cervicocerebral Arteries in Ascending Aortic and Arch Branches Dissection Mikhail Gordeev, Vladimir Uspenskiy, Anna Loginova, Dmitry Zverev, Artem Bakanov, Vitaliy Volkov, Olga Irtyuga, Alexandr Naimushin, Olga Moiseeva. Almazov Federal Medical Research Centre, Saint Petersburg, Russian Federation. Objective: In one-third of patients with an ascending aortic dissection, it affects cervicocerebral arteries, which may increase the risk of periop-erative adverse neurological events. The effectiveness of the hybrid ap-proach, including ascending aortic replacement and preventive stenting of cervicocerebral arteries, remains to be evaluated.
Methods: Between January 2010 and October 2016, 42 consecutive pa-tients (74% men, mean age 51.98 ± 11.31 years) with ascending aortic dissection (67% acute) involving the carotid arteries were operated on. All patients were divided into 2 groups: isolated ascending aortic replace-ment (group 1, 33 patients) and hybrid (group 2, 9 patients)—ascending FIGURE P4-1. Midterm survival rates in patients who shad only
the single-stage procedure, those who had both the first- and second-stage procedures, and those who had the first-stage procedure only.
aortic replacement with preventive stenting of dissected cervicocerebral arteries due to the collapse of the true lumen >70%.
Results: The mean cardiopulmonary bypass (178.20 ± 8.53 hours in group 1 vs. 182.75 ± 15.89 hours in group 2), cross-clamp (127.43 ± 7.01 vs. 129.00 ± 13.26 hours) and circulatory arrest times (32.07 ± 14.27 vs. 26.00 ± 11.53) did not differ significantly. Hemiarch repair was performed in 35 patients (83.3%), and there were no cases of total arch replacement. In 71%, we used axillary artery cannulation; in 24%, femoral artery cannulation; and in 5%, ascending aortic cannula-tion. We used antegrade cerebral perfusion and moderate hypothermia in 77% and 50% of patients in groups 1 and 2, respectively, and deep hypothermia in the other cases. The overall 30-day mortality rate was 7.1% (3 patients, 1 from group 1). Freedom from stroke was 86.7% in group 1 and 83.3% in group 2. We found a negative correlation of stroke with axillary artery cannulation (r =−0.463), and a positive correlation with femoral cannulation (r = 0.411). We found an insignificantly in-creased mortality rate (P = 0.05) and a similar rate of stroke (P = 0.443) in group 2 compared with group 1 (Fig. P6-1).
Conclusions: Preventive stenting of cervicocerebral arteries in ascend-ing aortic dissection is not associated with a significant increase in the mortality and stroke rates in patients with initially affected aortic arch branches. In case of femoral cannulation, such patients are at risk of ad-verse neurological events.
P7
Pitfalls of the Frozen Elephant Trunk Procedure: Our Experience With 54 Cases
Yoshito Sakon1, Takashi Murakami1
, Takeshi Ikuta2, Mitsuharu Hosono3, Takanori Tokuda4, Shinsuke Kotani5, Hiromichi Fujii1, Yosuke Takahashi1, Shinsuke Nishimura1, Daisuke Yasumizu1, Toshihiko Shibata1.1Osaka City Uni-versity Graduate School of Medicine, Osaka, Japan; 2Ishikiri Seiki Hospital, Higashiosaka, Japan;3Kansai Medical University Medical Center, Osaka, Japan; 4
Hirakata Kousai Hospital, Osaka, Japan; and5Belland General Hospital, Osaka, Japan.
Objective: The frozen elephant trunk (FET) procedure has recently been performed with increasing frequency, but there are some FET-specific complications. We retrospectively analyzed the complications related to this procedure using a multicenter registry database. Methods: A total of 54 patients who underwent the FET procedure be-tween January 2001 and September 2016 were eligible for analysis. The mean age of the cohort was 70.9 ± 10.3 years (77.8% men). The indica-tion for this procedure was a true aneurysm in 43 cases (79.6%), chronic aortic dissection in 3 (5.6%), and acute aortic dissection in 8 (14.8%). Handmade composite grafts with the Gianturco Cook-Z Stent (Cook Medical; Bloomington, IN USA) were used in 17 patients until December 2013, followed by the commercially available J Graft Open Stent Graft (Japan Lifeline; Shinagawa, Tokyo, Japan) in 36 cases. The conformable TAG Thoracic Endoprosthesis (W. L. Gore & Associ-ates; Flagstaff, AZ USA) was used in 1 patient. The proximal anastomo-sis site of the FET procedure was zone 0 in 9 cases (16.6%), zone 2 in 24 cases (44.4%), and zone 3 in 2 cases (3.7%). Thirty-three patients (61.1%) had concomitant graft replacement of the aortic arch, whereas the other patients had an FET insertion through the anterior half incision of the aortic wall (inclusion method).
Results: Four patients died during hospitalization. One FET-related cause of death was graft kinking and occlusion at the transition from nonstented to stented graft, leading to malperfusion and multiple organ failure. Another FET-related cause of death was bleeding after the inclu-sion method, requiring a second circulatory arrest. Complications related to the FET procedure were paraplegia in 3 cases (5.6%), graft kinking in 2 cases (one of which was mentioned above, and endovascular re-intervention in 1 case), ascending aortic dissection after the inclusion method in 1 case (1.6%), and FET inserted into the false lumen in 1 case. Conclusions: The FET technique was developed with the expectation that it would cause less of a surgical burden. However, several FET-specific complications have been identified that have to be conquered by the sur-geon technically and also by advancements in device technology. FIGURE P6-1. Dissected innominate and right common carotid arteries before (A) and after (B) stenting.
P8
Midterm Results of Endovascular Entry Closure for Type B Aortic Dissection
Atsushi Omura, Hitoshi Matsuda, Jiro Matsuo, Naoki Tadokoro, Yosuke Inoue, Yoshimasa Seike, Kyokun Uehara, Hiroaki Sasaki, Junjiro Kobayashi. National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
Objective: Entry closure using an endovascular technique has increas-ingly been applied in type B aortic dissection. However, the long-term outcomes of this approach have not been determined. We analyzed the midterm results of endovascular entry closure for aortic type B dissection.
Methods: From 2008 to 2013, 17 patients underwent entry closure using the endovascular technique. Mean age was 69 ± 9 years old. We performed 4 emergent operations (1 organ malperfusion and 3 rup-tures). In 13 elective cases, the mean and median operation days from the onset of type B aortic dissection were 94 days and 50 days, respectively.
Results: Technical success was achieved in all cases. Five patients re-quired revascularization of the left subclavian artery. Zone 2, 3, and 4 landings were 5, 7, and 5 cases, respectively. The mean operation time was 139 ± 83 minutes. We used 13 Gore TAG and 4 Zenith TX2 endoprostheses. A 79-year-old patient with chronic lung disease and re-nal failure died of multiorgan failure 3 months after the operation. Dur-ing the follow-up period of 35 ± 27 months, there were 2 late deaths (sudden death and senility). The survival rate at 3 years was 87.1 ± 8.6%. Computed tomography was performed 3 years after the operation in 11 patients (64.7%). All these patients had regression of the false lumen and of the whole aortic diameter at the site where the stent graft was deployed. No endovascular-related complications (infec-tion, aortic dissection at proximal or distal landing zone) were noted. Conclusions: We had favorable midterm results after entry closure using the endovascular technique for type B aortic dissection. However, we need a longer follow-up period.
P9
Complex Thoracoabdominal Aortic Aneurysm: Hybrid Debranching With Endovascular Repair
Fumikazu Nomura, Masato Suzuki, Shynsuke Ohori, Kiyotaka Morimoto, Kisyu Fujita, Yohei Ohkawa, Takemi Ohno. Hokkaido Ohno Memorial Hospital, Sapporo, Japan.
Objective: Thoracoabdominal aortic aneurysms remain a formidable surgical challenge with conventional open repair associated with sig-nificant rates of mortality and morbidity in the average center. The search for an alternative approach to managing these patients has led to the development of the so-called hybrid method of repair in-cluding complex visceral debranching and subsequent endovascular aneurysm exclusion.
Methods: From 2014 to 2017, 6 patients ranging from 50 to 78 years of age with Crawford type I (3), Safi V (3), and dissection (2) were oper-ated on. Open surgery was performed at the first stage. Complex vis-ceral debranching to the superior mesenteric artery and bilateral renal arteries was based off the concomitantly replaced infrarenal aorta using a commercially available 4-branched artificial graft (J Graft for total arch graft replacement). The celiac artery was not revascularized and ligated. Subsequent TAVR was performed a few days later.
Results: The mean operating time was 365 minutes, and the mean bleeding volume was 1243 ml. There were no operative deaths; the one major complication was right incomplete hemiplegia.
Conclusions: The visceral hybrid repair is a feasible and relatively safe procedure for an extensive thoracoabdominal aortic aneurysm. It may represent a viable alternative for patients with a high-risk thoracoabdominal aneurysm.
P10
Mini Open Stent Grafting With Half Sternotomy for Aortic Arch Aneurysm
Tamaki Takano, Takamitsu Terasaki, Masayuki Sakaguchi, Taishi Fujii, Magumi Fuke. Nagano Red-Cross Hospital, Nagano, Japan.
Objective: Aortic arch replacement is still considered invasive although organ protection and cardiopulmonary bypass during the operation have improved. Since March of 2015, we performed 5 cases of open stent grafting with a half sternotomy (mini-OSG) for an aortic arch aneurysm to reduce operation time and blood loss, both of which affect clinical outcomes. Our goal was to report our initial results.
Methods: Five consecutive patients with mini-OSG were enrolled in this study. The mean age was 62 ± 21 years (20–77 years), and all the patients were men. The etiology was dissection in 2 and aneurysm in 3 patients. An upper half sternotomy was performed until the fourth in-tercostal space was reached, and cardiopulmonary bypass was initiated with cannulation of the right atrium, the femoral artery, the left common carotid artery, and the right axillary artery. After induction of moderate hypothermia to a rectal temperature of 24 °C to 28 °C, selective antegrade cerebral perfusion was begun. An open stent graft (Japan Lifeline, Tokyo, Japan) that was 21 to 33 mm in diameter and 6 or 9 cm in length was inserted via an aortotomy on the aortic arch during circulatory arrest. The proximal end of the stent was sutured with the aortic wall. Two patients underwent reconstruction of the left subcla-vian artery with a prosthetic graft.
Results: No deaths were noted. One patient recovered to live a normal daily life although he presented with a cerebral infarction. The total op-eration time was 368 ± 74 minutes, the cardiopulmonary bypass time was 208 ± 54 minutes, and the arrest time was 77 ± 30 minutes. Blood loss was 528 ± 196 ml during the operation. The patients were weaned from the ventilator 7.1 ± 4.9 hours after the operation. No pseudoaneurysms or endoleaks were observed during the 2 to 20 months of the follow-up period.
Conclusions: Mini-OSG may be less invasive. Further studies with a large number of cases and intensive follow-up are needed.
P11
Thoracic Endovascular Aortic Repair and Open Operative Strategy for Chronic Type B Dissection
Masato Furui, Shoji Sakaguchi, Bunpachi Kakii, Gaku Uchino, Takeshi Yoshida. Matsubara Tokushukai Hospital, Matsubara, Osaka, Japan.
Objective: Thoracic endovascular aortic repair (TEVAR) is often per-formed for acute type B dissection but is accompanied by complica-tions. It is also used to prevent further expansion of a false lumen, but it has not yet been established as a treatment for chronic type B dissec-tion. However, treatment by open surgery for this chronic condition is so invasive that the less invasive combination with TEVAR has more ad-vantages. Therefore, we evaluated the results of staged surgical treat-ment using TEVAR for chronic type B dissection.
Methods: From December 2010 to May 2016, TEVAR was performed in 5 patients [mean 60 ± 15 (44–77) years old] who had chronic dissection in the arch and the descending aorta but needed additional treatment. The
cause of 4 cases was expansion of the aorta; the cause in 1 patient was dis-seminated intravascular coagulation by residual blood flow in the false lu-men. Using an open procedure, we fixed the inner artificial vessel of the stent graft with the outer felt-like sandwich under cardiopulmonary by-pass (CPB) after the stent graft was expanded by fenestration. The false lumen was closed using this procedure. We recorded the operative and CPB times, the respiratory effects such as prolonged ventilator manage-ment, the complications, the hospital stay, and the outcomes.
Results: The average operative time was 259 ± 42 minutes; the CPB time was 65 ± 30 minutes. There were no major operative complications such as respiratory failure and paraplegia. All patients were discharged well. The average hospital stay was 25 ± 9 days and the postoperative period was 15 ± 5 days. No additional treatment was needed due to en-largement of a false lumen, although the mean observational period thus far is 14 ± 11 (4–36) months.
Conclusions: First TEVAR and then a secondary open surgical false lu-men closure for chronic type B dissection had acceptable results includ-ing hospital stay, postoperative period, and complication rate. This staged treatment of combining TEVAR with closure of a false lumen is less invasive than open surgery alone and may be one option for treat-ment of chronic type B dissection.
P12
Advantage of Intraoperative Guidance by Preoperative Computed Tomography Angiogram Fusion in Endovascular Aortic Repair Masato Hayakawa, Shizuko Iwasa, Hiroyuki Tsukui. Hokkaido Cardiovascular Hospital, Sapporo City, Japan.
Objective: Our goal was to evaluate the advantages of fusing preopera-tive computed tomography angiography (CTA) with live fluoroscopy during endovascular aortic repair.
Methods: From February to July 2016, 3 procedures [thoracic endovascular aortic repair (TEVAR: 1) and endovascular aneurysm re-pair (EVAR): 2] were performed in a standard angiography room with-out CTA fusion (group NF). After August 2016, 8 procedures (TEVAR: 2; EVAR: 6) were performed using CTA fusion with live fluoroscopy (Discovery IGS 730; GE Healthcare, England) in a hybrid room (group F). Procedure time, fluoroscopy time, radiation exposure, and dosage of contrast agent were compared between the 2 groups.
Results: All patients in both groups underwent endovascular aortic re-pair successfully. There were no significant differences between the 2 groups (group NF vs. group F) in procedure time (66.7 + 5.8 minutes vs. 96.9 + 36.1 minutes, P = 0.056), fluoroscopy time (13.03 ± 2.95 minutes vs. 22.44 ± 9.76 minutes, P = 0.147), and radiation exposure (296.0 + 258.3 mGy vs. 345.3 + 209.6 mGy, P = 0.766). However, the dosage of the contrast agent was significantly decreased in group F (142.5 + 75.9 ml vs. 67.3 + 25.0 ml, P < 0.05).
Conclusions: The preoperative fusion of CTA images with live fluoros-copy results in a significantly reduced dosage of contrast agent for endovascular aortic repair.
P13
Epicardial Focal Electrocardiography Over Pulmonary Veins and Effectiveness of Surgical Ablation of Persistent Atrial Fibrillation Grzegorz Suwalski1, Jakub Mróz1, Robert Wierzbowski2, Kamil Kaczejko1, Robert W, Emery, Jr.3, Przemysław Szałański1, Leszek Gryszko1, Andrzej Cwetsch2, Andrzej Skrobowski2.1Department of Cardiac Surgery, Military Institute of Medicine, Warsaw, Poland;2Department of Cardiology, Military Institute of Medi-cine, Warsaw, Poland; and3Department of Cardiac Surgery, St Joseph’s Hospital, St. Paul, MN USA.
Objective: In patients referred to off-pump CABG and increased oper-ative risk, pulmonary vein isolation (PVI) may be used in patients with persistent atrial fibrillation (AF) as alternative to Cox Maze procedure. However, success rate of PVI in persistent AF is limited. Study aimed to assess the impact of recordings of epicardial focal PVs ECG on early antiarrhythmic outcomes after surgical off-pump ablation (PVI) of per-sistent AF.
Methods: There were 140 PVs mapped in 34 cases undergoing off-pump CABG mapped with use of sensing-pacing probe. In all patients PVI was confirmed with bidirectional conduction block assessment. Composite study end point consisted of need for electrical cardioversion due to in-hospital AF recurrence, the presence of AF at hospital dis-charge and after 3 months in 24-hour Holter ECG study.
Results: Four main types of electrical signals were recorded over PVs: sinus rhythm signal, focal trigger activity, fibrillation wavelet and far field signal (FF). Composite end point occurred in 61% of patients with epicardial FF signal recorded over at least one PV versus in 25% of pa-tients with FF signal recorded over none of PVs (P = 0.04). Presence of epicardial FF signal in at least one PV increased the risk of composite end-point occurrence (OR 3; P = 0.04). Average number of PVs with epicardial FF signal recorded was significantly higher in patients with positive end point (2.2 ± 1.4) in comparison to group with no early AF recurrence (1.3 ± 1.2; P = 0.04). Composite end point occurred in 86% of patients in whom epicardial far field signal was recorded over all PVs and in 39% of rest study population (P = 0.03). Epicardial re-cording of FF signal over all PVs increased the risk of composite study end-point occurrence (OR 1.5; P = 0.02).
Conclusions: Far field signal recorded over PVs with intraoperative epicardial focal ECG is related with worsen early outcomes after surgi-cal PVI in patients with persistent AF.
P14
Early Postoperative Pattern of Atrial Fibrillation Recurrence After Surgical Ablation Is Associated With Later AF Recurrence of Atrial Fibrillation
Efstratios I. Charitos1, Paul D. Ziegler2, Hendrik Treede3, Hans-Hinrich Sievers4, Thorsten Hanke5.1University of Halle (Saale), Halle, Germany;2Medtronic, Inc., Minneapolis, MN USA; 3University of Halle (Saale), Halle (Saale), Germany; FIGURE P12-1. This image demonstrates the fusion image
4University of Lübeck, Lübeck, Germany; and5ASKLEPIOS Clinic Harburg, Hamburg, Germany.
Objective: Ablation for atrial fibrillation (AF) can introduce periods of transient electrical instability for an extended period postoperatively. Several consensus statements indicate that arrhythmias observed in this so-called 3-month blanking period should not be taken into account when evaluating the success of the procedure. The aim of the present study was to evaluate if the quantity and temporal pattern of AF during the blanking period can provide valuable insights regarding future AF recurrence and indirectly the success of the ablation procedure. Methods: Ninety-nine patients (73 men; age 68.0 ± 9.2 years) with doc-umented preoperative AF (29 paroxysmal; 18 persistent; 52 long-lasting persistent; mean preoperative duration, 46 ± 53 months) underwent con-comitant biatrial surgical ablation (29 Cox-Maze III), full-set left atrium cryoablation (22), a high-intensity focused ultrasound box lesion (46) or right-sided ablation (2). Postoperative rhythm disclosure was provided via an implantable device. In all patients, the cardiac rhythm history was reconstructed. The quantity of AF recurrence (AF burden) and its tempo-ral aggregation (AF density) during the blanking period were regressed on the AF burden developed in the remaining observation time. Results: During the blanking period, AF recurrence was observed in 56/99 patients, with a median AF burden of 0.004 (interquartile range, 0.001–0.019), occurring with a median AF density of 0.87 (interquartile range, 0.68–0.96). During the remaining observation period, some AF recurred in 89/99 patients, although the AF burden of these patients dur-ing this period was negligible (median, 0.001; interquartile range, 0.0001–0.007). Both the AF burden (P < 0.0001) and the AF density (P = 0.004) observed during the blanking period were significantly associ-ated with later AF recurrence. This effect persisted after correcting for type of AF, type of ablation (energy source), and known preoperative AF dura-tion. A higher AF burden occurring with low AF density during the blanking period may indicate prolonged electrical instability and is associ-ated with higher AF recurrence during the remaining observation period. Conclusions: Small amounts of AF burden after surgical ablation are common. The quantitative and temporal characteristics of AF recurrence during the blanking period can provide valuable insights into the severity of electrical instability and the amount of later AF recurrence and may provide prognostic information on the success of the ablation procedure.
P15
Efficacy of the Left-Sided Maze Procedure During Robotic Mitral Valve Repair: The Mayo Clinic Experience
Lucman A. Anwer, Amit Taggarse, Hakan Akbayrak, Maurice E. Sarano, Hector I. Michelena, Joseph A. Dearani, Richard C. Daly, Simon Maltais. Mayo Clinic, Rochester, MN USA.
Objective: Atrial fibrillation (AF) is common in patients with degener-ative mitral valve disease. Because of a growing interest in robotic mitral
valve repair (MVR), attempts have been made to concomitantly address rhythm anomalies. Our goal was to report the outcomes of a left-sided Maze (LSM) procedure for AF in patients undergoing robotic MVR. Methods: From January 2008 to September 2016, 603 patients underwent robotic MVR for severe degenerative mitral regurgitation (MR). Medical records of 576 consenting patients were retrospectively reviewed to evaluate the efficiency of an LSM procedure. We analyzed rhythm outcomes with detailed postoperative echocardiogram findings including ejection fraction, recurrent MR, and residual gradient. Results: A total of 55 patients out of 576 were identified as having pre-operative AF: 9 were defined as persistent and 46 as paroxysmal. Of these, 39/55 underwent the LSM procedure; 8/9 patients in persistent AF were part of this cohort. Postoperatively, 15.4% (6/39) of patients in the LSM cohort had AF compared to 31.3% (5/16) in the non-LSM cohort (P = 0.27). The postoperative incidence of new-onset AF in a control group of patients with preoperative sinus rhythm (SR) was 19.1%. Over 1 year of follow-up, freedom from AF was 95.7% (22/23) in the LSM group vs. 83.3% (5/6) in the non-LSM group (Table P15-1). Early MVR outcomes demonstrated recurrent MR (mod-erate or greater) in 2% (12/575) of patients. Although univariate analy-sis failed to reveal a correlation between preoperative AF and postoperative MR grade, the left atrial volume index and pulmonary ar-tery systolic pressures were risk factors for early recurrent MR. Conclusions: Postoperative AF is common in patients undergoing ro-botic MVR. In patients with preoperative AF, a left-sided Maze proce-dure effectively restores SR and may reduce the incidence of postoperative AF. Although a concomitant LSM procedure effectively restores SR, a majority of patients convert to SR over time. AF does not portend increased risk of recurrent MR. Early referral plus improv-ing robotic MVr outcomes will likely continue to reduce the AF bur-den and improve long-term outcomes.
P16
Minimally Invasive Cox-Maze IV Procedure Concomitant With Mitral Valve Repair Has Excellent Short- and Long-Term Outcomes
Matthew R. Schill, Spencer J. Melby, Laurie A. Sinn, Richard B. Schuessler, Hersh S. Maniar, Ralph J. Damiano, Jr. Washington University in St. Louis, St. Louis, MO USA.
Objective: The Cox-Maze IV (CMIV) procedure performed via a min-imally invasive right minithoracotomy has been shown to be an effective treatment for atrial fibrillation (AF). This study examined short- and long-term outcomes with minimally invasive mitral valve repair (MIMVr) and a concomitant CMIV procedure at a single institution. Methods: Between November 2003 and May 2016, 65 consecutive patients underwent MIMVr and the CMIV procedure [biatrial 57/65, 88%; left atrial (LA)8/65,12%] via a right minithoracotomy. Outcomes
TABLE P15-1. Sinus Rhythm at Follow-Up Time Periods Sinus Rhythm (n = 519)
Atrial Fibrillation Plus Left-Sided Maze (n = 39)
Atrial Fibrillation Plus Non-Left-Sided Maze (n = 16) P-Value* (LSM vs. Non-LSM) SR (%) AF (%) SR (%) AF (%) SR (%) AF (%) Postoperative values 420 (80.9) 99 (19.1) 33 (84.6) 6 (15.4) 11 (68.7) 5 (31.3) 0.27 Discharge 513 (99.0) 5 (1.0) 35 (89.7) 4 (10.3) 16 (100.0) 0 (0.0) 0.31 >1 Year 258 (99.2) 2 (0.8) 22 (95.7) 1 (4.3) 5 (83.3) 1 (16.7) 0.38
The total number of patients having robotic MVr = 603; consenting participants analyzed = 574; patients with preoperative AF = 55. *Left-sided Maze vs. Non-left-sided Maze.
were evaluated using descriptive statistics. Freedom from atrial tachyar-rhythmias (ATA) was ascertained using electrocardiography, the Holter monitor, a loop recorder, or pacemaker interrogation at 1 to 5 years. Pro-longed monitoring was used in 47/65 patients (72%). Survival was ascertained from medical records. Data are expressed as median and in-terquartile range; freedom from ATA and from antiarrhythmic drugs (AAD) is expressed with 95% confidence intervals.
Results: Forty-nine percent (32/65) of the patients were men; the median age was 67 years. Most (38/65, 58%) had paroxysmal AF; the remainder had persistent AF (6/65, 9%) or long-standing persistent (21/65, 32%) AF. Twenty-one patients (32%) had functional mitral re-gurgitation (MR); 44 (68%) had degenerative MR. The median LA size was 4.7 cm (4.0, 5.4). Seven patients (11%) had a previous catheter ab-lation. Twenty-seven patients (42%) had New York Heart Association class III/IV heart failure. The median left ventricular ejection fraction was 0.60 (0.54, 0.65). The median cross-clamp time was 109 minutes (95, 119). There were no operative deaths or postoperative strokes. Ma-jor complications occurred in 9/65 patients (14%). The median time in the intensive care unit was 49 hours (24,96); the median hospital length of stay was 7 days (6, 9). Five patients (8%) required a postoperative pacemaker. Follow-up, freedom from ATA, and freedom from ATA and AAD were 85%, 98%, and 90% at 1 year and 80%, 88%, and 81% at 5 years, respectively (Fig. P16-1). At the median 2.3-year follow-up examination, survival was 92% (36/39). Only 3/62 patients (5%) developed≥2+ MR at 364 days postoperatively (96, 1265). Conclusions: MIMVr with the CMIV procedure is highly effective for AF and MR. This procedure is safe when performed at an experienced center.
P17
Perspectives and Outcomes Associated With the Convergence Procedure: A Data Review
Goya V. Raikar. Crossway Medical Clinic, Oklahoma City, OK USA.
Objective: Atrial fibrillation (AF) remains the most common cardiac arrhythmia affecting approximately 33.5 million individuals worldwide. Many of these patients fall into the“difficult to treat” subset and often face an uncertain future. Uncontrolled or untreated AF can lead to blood clots, stroke, heart failure, and other cardiac-related complications. There are several treatment options for AF. Although medications followed by endovascular surgical procedures are often the starting point, for patients who fail these treatments, the convergent procedure may be the best option to treat their persistent AF. The convergent pro-cedure comprises the best from electrophysiology and cardiothoracic operations to produce the best results within this patient population. The convergent procedure is a closed chest procedure with a minimally invasive abdominal incision. This procedure allows for a shorter stay in the hospital along with a faster recovery period. Our goal was to share the results of a convenience sample from 212 patients with AF who had the convergent procedure in a specialty hospital in Oklahoma City, OK in the United States.
Methods: Although multiple data points were reviewed from the sam-ple, the main end points of this study were as follows: (1) After the con-vergence procedure, how long does the patient remain in normal sinus rhythm (versus return to AF)? (2) Did the convergence procedure allow a decrease in the use of anticoagulants?
Results: Of the 212 patients in our sample, 199 (94%) remained in normal sinus (AF free) for more than 2 years. These data were captured by a real-time loop placed at the time of the procedure. When we re-viewed the data on anticoagulants, we found that 205 of the 212 patients (97%) remained off anticoagulants for more than 2 years. Conclusions: When we looked at treatment options for uncontrolled AF, we found that the convergence procedure remains a strong option for this subset of patients. Although these results are positive, future re-search is necessary to help solidify the convergence procedure as the new gold standard for patients with uncontrolled AF.
P18
Stroke Prevention With the Totally Thoracoscopic Left Atrial Appendage Epicardial Clipping System in High-Risk Patients With Atrial Fibrillation
Anna Witkowska1, Grzegorz Suwalski2, Dominik Drobinski1, Jakub P. Staromłyński1, Radoslaw Smoczynski1, Dariusz Kosior1, Piotr Suwalski1.1Central Clinical Hos-pital of the Ministry of Interior in Warsaw, Warsaw, Poland; and2Military Institute of Medicine in Warsaw, Warsaw, Poland.
Objective: In approximately 90% of patients, the source of thrombotic material is the left atrial appendage (LAA). The standard of care re-mains oral anticoagulation; however, not every patient is eligible for this therapy. Although results in the literature indicate that closure of the LAA might not be inferior to oral anticoagulation, a number of novel techniques for LAA exclusion have been recently described. Our goal was to present early results of the novel clipping system for the totally thoracoscopic epicardial LAA exclusion for primary and secondary stroke prevention in high-risk patients with atrial fibrillation.
Methods: Twenty patients (9 women) with a mean age of 72 (±9) years with long-standing persistent atrial fibrillation were admitted for totally thoracoscopic LAA exclusion. All patients had significant comorbidities and a history of intolerance to oral anticoagulants or prior stroke. The mean left ventricle ejection fraction was 47% (±16%); the mean left atrium dimension was 46 mm (±2 mm). The CHA2DS2VASC score was from 2 to 7 and the HAS_BLED score was 2 to 7. Concomitant total thoracoscopic ablation was performed in 4 patients. In 2 patients, FIGURE P16-1. Freedom from atrial tachyarrhythmias (ATA) and
ATA/antiarrhythmic drugs (AAD) after minimally invasive mitral valve repair concomitant with the Cox-Maze IV procedure.
concomitant endoscopic coronary artery bypass grafting was per-formed. Transesophageal echocardiography was performed in all pa-tients to rule out thrombus in the LAA and to guide the deployment of the clip at the base of the left atrium appendage.
Results: The perioperative period was uneventful. The clip measure and deployment took 10 (±5) minutes. Patients were extubated in the oper-ating room directly after the procedure. Patients were discharged several days later. During the mean follow-up period of 6 to 12 months, we did not observe any bleeding events, strokes, transient ischemic attacks, or deaths. A stable clip position without a stump or leakage was confirmed by echocardiography or computed tomography.
Conclusions: Totally thoracoscopic LAA exclusion using a novel epi-cardial clipping system for stroke prevention in high-risk patients is safe and effective with a low risk of complications both as a stand-alone pro-cedure or concomitant with other cardiac propro-cedures. Our initial experi-ences are extremely promising: We found high efficacy and a good safety profile. Further studies are warranted.
P19
Thoracoscopic Left Atrial Appendectomy Can Be an Alternative to Anticoagulation Therapy in Patients With Atrial Fibrillation Takafumi Inoue1, Toshiya Ohtsuka2, Yoshihiro Suematsu1.1Tsukuba Memorial Hospital, Tsukuba, Japan; and2Tokyo Metropolitan Tama Medical Center, Tokyo, Japan.
Objective: Although anticoagulation therapy is the gold standard of prophylaxis for cardiogenic thromboembolism in patients with atrial fi-brillation (AF), thromboembolic events sometimes occur even when one is administering anticoagulants. Thoracoscopic left atrial appendec-tomy (TLAA) has been suggested as a new approach to prevent cardio-genic thromboembolism in patients with AF; we examined the effectiveness and safety of this surgical method.
Methods: Sixty consecutive patients (mean age, 70 ± 7 years, 46 men, mean CHA2DS2-VASc score, 2.9 ± 1.6 points) with a high risk of thromboembolism and/or bleeding were selected for TLAA. Fifty-seven of these patients had been treated with anticoagulants preopera-tively. (Three patients had stopped anticoagulation therapy due to the negative side effect of bleeding.) Seventeen patients had suffered a stroke/transient ischemic attack (TIA), and 2 patients had a history of thromboembolism before undergoing the operation. In addition, ce-rebral hemorrhage had also developed in 5 patients preoperatively. The left atrial appendage was excised with an endoscopic linear cutter thoracoscopically with the patient in the right lateral recumbent posi-tion with differential lung ventilaposi-tion. Four endoscopic ports (for the endoscope, endoscopic cutter and forceps) were normally made in the left thorax while the surgical team monitored the procedures using transesophageal echocardiography.
Results: TLAA (mean operation time 37 ± 9 minutes) resulted in no deaths and no major complications. All of the patients were discharged and were able to maintain their activities of daily living in the erative period of 4.3 ± 1.8 days. Anticoagulants were stopped postop-eratively and no cardiogenic thromboembolism events occurred; the mean follow-up duration was 16 ± 7 months. The rates of freedom from cardiogenic thromboembolism were significantly different between the preoperative and postoperative periods in the same groups of patients (preoperatively with anticoagulants) (P < 0.01 log-rank test, Fig. P19-1). Conclusions: TLAA is considered a safe, effective approach for the prophylaxis of cardiogenic thromboembolism. Especially for patients who are refractory to (or contraindicated for) anticoagulants, this oper-ation would be an optimal therapeutic option.
P20
Significant Elevated C-Reactive Protein Levels After Epicardial Clipping of the Left Atrial Appendage
Ferdi Akca, Niels Verberkmoes. Catharina Hospital Eindhoven, Eindhoven, Netherlands.
Objective: Closure of the left atrial appendage (LAA) is a common ad-dition in current surgical procedures for the treatment of atrial fibrilla-tion. Besides the mechanical and anatomical changes of the left atrium, epicardial closure of the LAA also induces biochemical effects. The aim of this study was to assess whether epicardial clipping of the LAA results in an elevated inflammatory response compared to com-plete removal of the LAA.
Methods: A total of 73 patients were included in this study. All pa-tients underwent a totally thoracoscopic Maze procedure. As part of the procedure, the LAA was excluded. LAA exclusion was performed with an epicardial clip (n = 48) or the LAA was fully amputated with an endoscopic vascular stapler (n = 25). Postoperative inflammatory parameters were collected from all patients and were compared be-tween the 2 groups.
Results: The mean age and left atrial volume index were comparable between the epicardial clip and stapler groups (64 ± 8 vs. 60 ± 9 years, P = 0.101; 43 ± 11 vs. 40 ± 12 mL/m2). Patients receiving the LAA clip-ping had significantly elevated C-reactive protein levels compared to patients who had LAA stapling at the second, third, fourth, and fifth postoperative day (219 ± 80 vs. 149 ± 75 mg/L, P = 0.004; 239 ± 77 vs. 167 ± 75, P = 0.008; 183 ± 75 vs. 104 ± 47, P < 0.001; 129 ± 63 vs. 72 ± 28, P = 0.040, respectively) (Fig. P20-1). The white blood cell count was comparable between the 2 groups.
FIGURE P19-1. Freedom from stroke/transient ischemic attack/thromboembolism.
FIGURE P20-1. Postoperative levels of C-reactive protein for the stapling and epicardial clip device groups.
Conclusions: Epicardial clipping of the LAA is a surgical technique with a high success rate of mechanical closure of the LAA. We observed significant elevated levels of the C-reactive protein, which could be a re-sult of LAA tissue necrosis. Whether this inflammatory response affects the outcome of arrhythmia surgery or induces the prothrombotic state needs to be evaluated in further studies.
P21
Endocardial Left Atrial Appendage Device Implantation During Hybrid Atrial Fibrillation Ablation (WINNING Trial): First Results
Mindy Vroomen1, Bart Maesen1
, Mark La Meir2, Jos Maessen1, Harry Crijns1, Laurent Pison1.1Maastricht University Medical Center, Maastricht, Netherlands; and2UZ Brussel, Brussel, Belgium.
Objective: The WATCHMAN Left Atrial Closure Device (Boston Scientific, Marlborough, MA USA) reduces the risk of stroke by closing off the left atrial appendage (LAA). We studied the safety and feasibility of implantation in a hybrid atrial fibrillation (AF) ab-lation setting (combination of epicardial surgical and endocardial catheter ablation).
Methods: In this prospective, single-center, nonrandomized trial (the WINNING Trial), 10 consecutive patients with drug-refractory AF who qualified for a hybrid AF ablation procedure with the necessity of LAA exclusion (CHA2DS2-VASc≥ 1) were included. For the im-plantation and periprocedural care, we followed the standard protocol. The primary safety end point comprised major complications (e.g., stroke, device embolization, and device-related complications). The pri-mary feasibility end point was successful implantation. Secondary end points were procedure time, radiation exposure, (serious) adverse device events, and (serious) adverse events. The follow-up period was 6 months. Results: At the beginning of October 2016, the first 8 procedures were performed. The device was deployed successfully in all patients (Fig. P21-1). The total procedure time (ablation and implantation) was prolonged by a mean of 33 minutes; radiation exposure time, by 6 minutes; and radiation dose by 28 mGy. One adverse event occurred 3 days after the procedure (bleeding that required a blood trans-fusion). After 6 weeks, a transesophageal echocardiogram was per-formed that showed good positioning of the device without significant peridevice flow. Oral anticoagulation was discontinued, and clopidogrel was started.
Conclusions: The WINNING Trial (NCT02471131) investigated the safety and feasibility of the Watchman device in a hybrid AF ablation setting, with encouraging preliminary results.
P22
The Thoracoscopic Maze Procedure in Obese Patients
Tyler M. Gunn, Michael D. Bolanos, Theodore S. Wright. University of Kentucky, Lexington, KY USA.
Objective: Atrial fibrillation is a common arrhythmia that is associated with increased risk of thromboembolism, stroke, and death. Historically, the traditional open Cox-Maze procedure has been the standard for sur-gical management of atrial fibrillation and requires a sternal incision with cardiopulmonary bypass. However, a minimally invasive technique has been developed called the Cox-Maze IVor thoracoscopic Maze pro-cedure, which allows for pulmonary vein radiofrequency isolation, pos-terior atrial wall debulking via superior and inferior connecting lesions, and epicardial left atrial appendage exclusion without requir-ing a sternal incision, cardiac arrest, or cardiopulmonary bypass. Risk factors for adverse outcomes for this procedure based on preoperative patient characteristics are not well understood. Obesity is a common preoperative risk factor that may increase the technical difficulty of the surgical procedures, especially minimally invasive techniques. This retrospective study investigated the impact of obesity on postoperative outcomes as well as on short- and long-term successful conversion to sinus rhythm.
Methods: Seventeen consecutive patients undergoing thoracoscopic Maze surgery at the University of Kentucky from December 1, 2013 to February 3, 2016 were included in this retrospective chart review. Preoperative characteristics, intraoperative technique, and outcomes were assessed, including short- and long-term clinical follow-up with electrocardiograms.
Results: Eleven of 17 patients in the study were obese (65%) with a body mass index greater than 30. Of those who were obese, 7 patients (64%) had persistent atrial fibrillation and 4 patients (36%) had parox-ysmal atrial fibrillation. Ten obese patients (91%) had successful con-version to normal sinus rhythm documented during the clinical follow-up period. The length of the follow-up period ranged from 2 weeks to 20 months. There were no operative deaths, and no opera-tions were converted intraoperatively to an open technique.
Conclusions: Obesity is a common preoperative characteristic that is thought to increase the difficulty of minimally invasive surgery and may worsen outcomes. In a cohort of obese patients undergoing thoracoscopic Maze procedures, we have demonstrated a high rate of successful conversion from refractory atrial fibrillation to normal si-nus rhythm without adverse outcome or intraoperative conversion to an open Maze procedure.
P23
Minimally Invasive Thoracoscopic Surgery Is an Effective Approach for Inappropriate Sinus Tachycardia
Seyed Hossein Aalaei Andabili1, William Miles2
, Thomas Burkart2, Matthew Mckillop2, Juan Garcia2, Thomas Beaver1.1
Division of Thoracic and Cardiovascu-lar Surgery, Gainesville, FL USA; and2Division of Cardiology, Department of Medi-cine, University of Florida, Gainesville, FL USA.
Objective: Inappropriate sinus tachycardia (IST) is an uncommon ar-rhythmia characterized by an increased heart rate that is out of propor-tion to normal physiological demand. IST is challenging for the electrophysiology community due to the risk of phrenic nerve (PN) in-jury during ablation. In this study, we investigated the safety and effi-cacy of a minimally invasive thoracoscopic procedure for elimination of the IST focus.
FIGURE P21-1. Left-sided thoracoscopic view of the left atrial appendage before and after implantation of the Watchman device, showing almost no difference in appearance.
Methods: Patients with IST who failed endocardial ablation underwent minimally invasive thoracoscopic epicardial ablation. Epicardial activa-tion mapping was performed to identify the earliest activaactiva-tion site and any possible migration pathway. The phrenic nerve in each patient was protected by a pericardial retraction suture. Patients’ outcomes were reviewed retrospectively.
Results: From January 2000 to September 2016, 9 patients (7 women and 2 men) underwent minimally invasive thoracoscopic IST abla-tion at our university center. The mean age of the patients was 37 ± 13 years. All patients were treated with rate/rhythm control med-ications and had prior endocardial ablation, with the highest attempt being 13 ablations. The most common concomitant comorbidity was asthma (N = 4, 45%). Two (22.2%) other patients noticed symp-toms following pregnancy. The mean baseline sinus rate was 117 ± 17 beats per minute (Table P23-1). After the operation, the mean heart rate decreased significantly on postoperative day 1 (117 ± 17 versus 85.33 ± 8 beats per minute, P < 0.001). No in-hospital deaths, strokes, or phrenic nerve injuries were detected. One patient required re-intubation; 1 patient developed postoperative pericarditis; and 1 patient had a pulmonary embolism. The median follow-up time was 6 months (range, 1–30). Freedom from re-intervention was 88% at 6 months. All patients remained free from medication after the operation, except 2 who needed re-intervention at 4 months and 12 months (Table P23-1).
Conclusions: Minimally invasive thoracoscopic ablation for IST is a safe and effective approach that preserves the phrenic nerve. Due to the possibility of IST activation site migration, continued follow-up after the operation is required.
P24
Minimally Invasive Laser Lead Extraction: Infected Versus Noninfected Leads
Simon Pecha, Nils Gosau, Stephan Willems, Hermann Reichenspurner, Samer Hakmi. University Heart Center Hamburg, Hamburg, Germany.
Objective: We investigated the effect of systemic infection or lead endocarditis on the difficulty and success of laser lead extraction (LLE) procedures.
Methods: Medical records of all patients undergoing LLE between January 2012 and August 2015 were screened with regard to sufficient information on systemic infection or lead endocarditis. We used high-frequency 80-Hz laser sheaths in 101 patients with a lead implant du-ration of≥24 months. Indications for lead extraction were systemic infection and lead endocarditis (29.7%), local infection (49.5%), lead
dysfunction (15.8%), upgrades (3.0%), and tricuspid insufficiency (2.0%). A total of 239 leads were scheduled for LLE: 175 pacing and 64 implantable cardioverter defibrillator leads; the mean time from ini-tial lead implantation was 96.5 ± 65.5 months (range, 24–408). The pa-tient lead distribution with regard to systemic infection or lead endocarditis was systemic infection and lead endocarditis (group A): 30 patients, 78 leads; local infection and other extraction indications (group B): 71 patients, 161 leads.
Results: Complete procedural success was significantly higher in group A than in group B (100% vs. 94.4%; P = 0.0331). The laser treat-ment time and fluoroscopy time were numerically lower in group A. Mean time from initial lead implantation (103.4 vs. 89.6 months; P = 0.1320), and the ratio of implantable cardioverter defibrillator leads (28.2% vs. 26.1%; P = 0.7566) did not differ significantly between the 2 groups. Minor and major complications were low in both groups and did not reveal any significant differences (group A: 1 minor complication—pocket hematoma; group B: 2 major complications— pericardial effusion and emergent sternotomy due to perforation of the su-perior vena cava). No extraction-related deaths were observed. Conclusions: The presence of systemic infection or lead endocardi-tis in LLE procedures allows for more complete procedural suc-cesses. When compared with LLE of noninfected leads, the infected leads require less laser and fluoroscopy time. Due to the small number of minor and major complications, no statistical sig-nificance was found in that regard.
P25
Minimally Invasive Implantation of Left Ventricular Assist Devices: Safe Implementation Early In a Surgical Career
Hannah J. Voorhees, Erik N. Sorensen, Chetan Pasrija, Francesca Boulos, Bartley P. Griffith, Zachary N. Kon. University of Maryland Medical Center, Baltimore, MD USA.
Objective: Several centers offer minimally invasive surgical approaches for implantation of centrifugal left ventricular assist devices. Although these large centers have found that minimally invasive implantation can be successfully performed by experienced surgeons, it is unknown whether these techniques are widely adoptable. We compared conven-tional and minimally invasive surgical approaches performed by a sur-geon early in his career.
Methods: All consecutive left ventricular assist device implantations by a single surgeon in his first year of practice (2015–2016) were retro-spectively reviewed. Patients were stratified by the standard approach, a conventional full sternotomy (CS), versus a minimally invasive TABLE P23-1. Patients’ Preoperative Characteristics and Postoperative Outcomes
Patient Age Gender Prior Attempts Failed Medications Prior Cardiac Diagnosis Baseline HR POD 1 HR 30-Day HR
1 34 M 1 BB, CCB, and digoxin None 117 89 –
2 47 F 1 BB and CCB Atrial fibrillation 131 101 –
3 46 F 2 BB and CCB Atrial fibrillation 94 88 74
4 23 M 13 BB and CCB AVNRT 120 75 77
5 61 F 1 BB and CCB Atrial fibrillation 104 80 75
6 44 F 2 BB and CCB None 108 85 80
7 21 F 1 BB, CCB, flecainide, and digoxin None 123 87 89
8 31 F 1 BB None 106 75 74
9 28 F 3 BB, CCB, and flecainide AVNRT 150 88 85
approach, and a left anterior thoracotomy and upper hemisternotomy (LTHS). Demographic and perioperative variables and short-term out-comes were compared.
Results: Thirteen patients were identified (CS = 6, LTHS = 7). Preop-erative age, INTERMACS score, and creatinine and total bilirubin levels were comparable in the CS and LTHS groups, with significantly more preoperative right ventricular dysfunction in the LTHS group (P = 0.01). Operative time was significantly shorter (P = 0.02) in the CS group compared to the LTHS group, but cardiopulmonary bypass time trended toward statistically shorter times in the LTHS group. One patient who began with the LTHS was converted to a full sternotomy due to intraoperative bleeding, but no patients in either group required a right ventricular assist device. Although not statistically significant, the lengths of stay in the intensive care unit and in the hospital were also nominally reduced in patients who received LTHS implants. The 6-month survival rate in both groups was 100%.
Conclusions: In this small series, LTHS appears at least comparable if not superior to CS in regard to perioperative outcomes. Although the operative time was longer in LTHS, it was still within the learning curve of a sur-geon’s initial experience. Overall, this minimally invasive approach appears to be safe, efficacious, and adoptable by surgeons early in their careers.
P26
Impact of Right Ventricular Function for Worse Outcome After CABG With or Without Surgical Ventricular Reconstruction Sachiko Yamazaki, Hitoshi Yaku, Satoshi Numata, Keiichi Itatani, Kazuki Morimoto, Suguru Ohira, Haruka Fu. Kyoto Prefectural University of Medicine, Kyoto, Japan.
Objective: The prognostic value of right ventricular (RV) function for patients with ischemic cardiomyopathy who underwent coronary artery bypass graft (CABG) with or without surgical ventricular reconstruc-tion (SVR) is still unknown. The purpose of the study was to clarify whether cardiac magnetic resonance imaging (MRI)-derived RV assess-ment can facilitate risk stratification among patients who underwent CABG with or without SVR.
Methods: We retrospectively analyzed 163 patients (109 men; age, 66 ± 10 years) with ischemic cardiomyopathy and a left ventricular ejec-tion fracejec-tion of 40% or less who were evaluated using cardiac MRI pre-operatively and who underwent CABG with (n = 53) or without
(n = 110) SVR from 2004 to 2014. Cine-MRI images had been acquired for left and RV volumetric measurements. Patients were divided into 2 groups: those with RVEF≤ 35% (group RF: n = 38) and those with RVEF >35% (group C: n = 125). The midterm (median, 3.8 years) result of all-cause deaths was evaluated, and interactions between RV function and treatment allocation were also analyzed.
Results: The mean preoperative left ventricular end-systolic volume in-dex was significantly higher (133 ± 44 vs. 90 ± 32 ml/m2, P < 0.01) and the left ventricular ejection fractions were significantly lower (29 ± 8 vs. 18 ± 5%, P < 0.01) in group RF. The mean right ventricular end-systolic volume index was also significantly higher (64 ± 27 vs. 31 ± 9 ml/m2, P < 0.01) and the right ventricular ejection fractions were lower (50 ± 7 vs. 26 ± 7%, P < 0.01) in group RF. A Kaplan-Meier analysis showed that group RF patients had a greater but not significant incidence of all-cause death (5-year; 66% vs. 78%, P = 0.21). A significant interaction between RV dysfunction and treatment allocation was observed. Group RF patients who underwent CABG had similar incidences of all-cause death (P = NS; Fig. P26-1A) compared with group C patients who underwent CABG. However, group RF patients who received CABG concomitant with SVR had significantly worse outcomes compared with group C patients who received concomitant SVR (P = 0.013, Fig. P26-1B).
Conclusions: RV dysfunction may affect the midterm outcome after CABG concomitant with SVR, despite the fact that it did not affect the outcome after CABG without SVR.
P27
Blood Flow Through the Bioprosthetic Aortic Valve: Blood Flow Visualization and Energy Dynamics Based on 4-Dimensional Flow Magnetic Resonance Imaging
Rina Makino1, Keiichi Itatani1
, Satoshi Numata1, Sachiko Yamazaki1, Kazuki Morimoto1, Suguru Ohira1, Haruka Hu1, Shohei Miyazaki2, Teruyasu Nishino2, Kosuke Nakaji1, Kei Yamada1, Hitoshi Yaku1.1Kyoto Prefectural University of Medicine, Kyoto, Japan; and2Cardio Flow Design Inc., Tokyo, Japan.
Objective: Our goal was to evaluate the flow characteristics of bioprosthetic aortic valves including porcine aortic and bovine pericardial valves based on 4-dimensional flow magnetic resonance imaging. Flow energy loss through the aortic valve and output kinetic energy (KE) at the ascending aorta were estimated from the visualized blood flow.
FIGURE P26-1. Kaplan-Meier curves for all-cause mortality in patients with and without RV dysfunction who underwent CABG (A) and in patients who underwent surgical ventricular reconstruction concomitant with CABG (B).
Methods: Two healthy volunteers and 5 patients were examined after aortic valve replacement (AVR) with 4-dimensional flow magnetic res-onance imaging (3-dimensional time-resolved flow magnetic resres-onance imaging): 2 cases with a bovine pericardium valve (Carpentier-Edwards Perimount Magna, Edwards Lifesciences Corp., Irvine, CA USA) (21 and 25 mm), and 3 cases with a porcine aortic valve (Medtronic Mosaic Ultra, Medtronic Inc., Minneapolis, MN USA) (23 mm in 2 cases and 27 mm in 1 case). The cardiovascular lumen was extracted with a superimposed steady-state free precession series for pulsatile 3-dimensional flow visualization. Output kinetic energy at the ascend-ing aortic level and flow energy loss through the aortic valve were cal-culated from the measured flow.
Results: The ages of the healthy volunteers and of the patients with AVR with the bovine pericardium valve and AVR with the porcine aor-tic valve were 35.5 ± 2.1, 77.5 ± 5.0, and 73.7 ± 8.7 years old, respec-tively. The flow rates of these 3 groups were 5.10 ± 0.49, 3.03 ± 0.01, and 3.39 ± 0.18 L/minute, respectively. The flow streamline of the healthy volunteers was a slightly helical flow along the curve of the arch (Fig. P27-1A), and the energy loss and kinetic energy were 1.62 ± 0.54 and 5.13 ± 3.39 mW, respectively. The flow streamline through the bovine pericardium valve became straightforward and collided with the distal portion of the ascending aortic wall, resulting in a vertical vortex inside the ascending aorta (Fig. P27-1B). The en-ergy loss and kinetic enen-ergy were 2.98 ± 0.53 and 3.95 ± 0.21 mW. The flow streamline through the porcine aortic valve was a highly he-lical flow inside the ascending aorta (Fig. P27-1C); and energy loss and kinetic energy were 3.39 ± 1.09 and 5.82 ± 3.00 mW.
Conclusions: The porcine aortic valve and the bovine pericardium valve exhibited characteristic flow patterns. Compared with the normal control, flow through the bioprosthetic aortic valve caused a high energy loss. He-lical flow inside the ascending aorta caused a high kinetic energy output.
P28
Usefulness of the Indocyanine Green Direct Injection Method Using the Spy System
Masao Takahashi1, Keisuke Miyajima1
, Hirotaro Sugiyama1, Toshihiro Ishikawa2, Kazuyoshi Hatada2.1Hiratsuka Kyosai Hospital, Hiratsuka, Japan; and2Odawara Municipal Hospital, Odawara, Japan.
Objective: The SPY system is the first commercially available fluores-cence angiographic device that allows surgeons to assess the bypassed graft during the surgical procedure. The prototype of the SPY system
(SP1000) was introduced in 2002. The second generation (SP2000) was used from 2002 to 2015. The latest version, which includes a color mode (SP3000), was introduced in July 2015. At our institute, 100% of isolated coronary procedures were performed with off-pump coronary artery bypass grafting. SPY intraoperative graft validation was routinely used in more than 700 cases. Since May 2016, the new technique has been used for the free graft.
Methods: We first identify the target coronary artery using the SPY sys-tem. After the distal anastomosis is completed, diluted indocyanine green (ICG) is mixed with heparinized blood and injected directly into the free graft while the SPY system is recording. After the proximal anastomo-sis is completed, SPY imaging with natural flow is performed by injecting diluted ICG via the central venous line.
Results: Before the anastomosis, the target coronary artery can be identified using the SPY system. It is especially helpful in totally oc-cluded branches. Just after completion of the anastomosis, visual con-firmation of the patency of the graft can be obtained. The ICG direct injection method has been extremely useful (Fig. P28-1), especially when the target artery is small, about 1 mm diameter, and the surgeon is concerned about the patency of the anastomosis or when the anasto-mosis is performed by an inexperienced resident. The sequential by-pass grafting could be avoided in 4 cases because the neighboring coronary artery could be stained just after direct injection of ICG. All bypass grafts including in-situ grafts were routinely evaluated FIGURE P27-1. Flow pattern in various types of the aortic valve. A, In healthy volunteers, smooth helical flow was observed in the aorta. B, In bovine pericardial aortic valve, straightforward flow collided with the ascending aorta and vertical vortex was observed in the ascending aorta. C, In porcine aortic valve, highly helical spiral flow was observed in the aorta.
FIGURE P28-1. ICG direct injection method just after distal anastomosis of the free graft.
